Female Testosterone Injection Intake, Consent & Provider Note

Female Testosterone Injection Intake, Consent & Provider Note

Complete this form to provide your medical history, consent, and understand the treatment process.
Patient Intake
Full Legal Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Driver's license number
Driver's license expiration date

MonthDayYear
Date
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider Name
Current Medications (list all prescription and non-prescription medications)
Allergy Information
List each allergy separately if you have more than one.
No known drug allergies?
Medication/Substance allergy
Allergy severity
Allergy details
Currently pregnant?
Currently breastfeeding?
Last menstrual period (if applicable)

MonthDayYear
Date
History of hysterectomy?
History of oophorectomy?
Menopause or perimenopause?
Current estrogen therapy?
Current progesterone therapy?
History of breast cancer?
History of uterine/endometrial cancer?
History of ovarian cancer?
Unexplained vaginal bleeding?
PCOS?
Acne or hirsutism?
Hair thinning?
Voice changes?
Liver disease?
Cardiovascular disease?
History of clotting issue or blood clot?
Trying to conceive?
Have you used testosterone before?
Have you used anabolic steroids before?
Check any symptoms you are currently experiencing:

Other
Check any medical conditions you have (past or present):

Other
Safety Questions
Safety Questions (check any symptoms you are currently experiencing):
If you are experiencing any urgent symptoms, seek emergency care immediately. Do not wait for this visit.
Patient Acknowledgments / Consent
I certify that the information I provided is true, accurate, and complete to the best of my knowledge.
Patient Acknowledgments and Consents (check all to proceed):
Patient Signature
Date Signed

MonthDayYear
Date
Provider Clinical Note
Attach picture of written prescription

Cancelof
Attach picture of patient labs

Cancelof
Provider Uploads
Provider Name
Date/Time of Visit

MonthDayYear
Date
Hour MinutesAM/PM Option
Chief Complaint
HPI (History of Present Illness) Summary
Date of last women’s health screening

MonthDayYear
Date
Medical History Reviewed
Symptoms Reviewed
Contraindications Reviewed
Height
Weight
Blood Pressure
Heart Rate
Respiratory Rate
Oxygen Saturation
Temperature
Pain Scale
Physical Exam
Lab Review — Other
Last Lab Date

MonthDayYear
Date
Assessment (check all that apply):

Other
Provider Plan/Instructions

Other notes
Provider Attestation: I certify this documentation is accurate and complete.
Provider Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Female Testosterone Injection Intake, Consent & Provider Note

Patient Intake

Allergy Information

Safety Questions

Patient Acknowledgments / Consent

Provider Clinical Note

Provider Uploads